Provider Demographics
NPI:1619920881
Name:BROCK, DEBORAH LEE (DIETICIAN)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:LEE
Last Name:BROCK
Suffix:
Gender:F
Credentials:DIETICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 TOWNSEND VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:KY
Mailing Address - Zip Code:40361-9757
Mailing Address - Country:US
Mailing Address - Phone:859-987-7249
Mailing Address - Fax:
Practice Address - Street 1:1210 KY HIGHWAY 36 E
Practice Address - Street 2:
Practice Address - City:CYNTHIANA
Practice Address - State:KY
Practice Address - Zip Code:41031-7490
Practice Address - Country:US
Practice Address - Phone:859-234-2300
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-1184133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered